Continuous ulnar nerve block at the forearm for early active mobilisation following flexor tendon reconstruction

A 63-year-old woman had sustained a subcutaneous rupture of the flexor digitorum profundus tendon of the little finger due to osteoarthritis of the pisotriquetral joint. She underwent excision of the pisiform bone and reconstruction of the flexor digitorum profundus tendon of the little finger using an autogenous palmaris longus tendon graft. After surgery, a continuous ulnar nerve block was performed at the forearm under ultrasound and nerve stimulator guidance. During rehabilitation, she could not actively extend her little finger independently due to the block; however, she could actively extend it when the dorsum of the metacarpophalangeal joint was pressed by the occupational therapist, resulting in successful early active mobilisation. A continuous ulnar nerve block at the forearm may help to facilitate early active mobilisation after reconstructive surgery for little finger flexor tendon rupture. However, it may restrict the active extension of the little finger because the block does not spare the innervation of the intrinsic muscles responsible for little finger extension.

Potential impact factors on the enhancement of antibiotic resistance in a lake environment

There is considerable concern regarding antibiotic resistance in the water environment due to antibiotic residues from anthropogenic origins. The low antibiotic concentration in the water environment may promote the selection of antibiotic resistance. However, it is unclear how environmental factors affect resistance selection. We investigated the proliferation of quinolone-susceptible faecal bacteria (E. coli) exposed to low norfloxacin concentration (ng/L) at variable temperatures, exposure times, and carbon concentrations, simulating the conditions of the water environment. The induction of antibiotic resistance in thirteen E. coli isolates was more likely to occur at 37 °C. However, resistance also occurred at temperatures as low as 25 °C, provided a longer exposure time of 5 days. These results suggest that antibiotic resistance is more likely to be induced in regions where temperatures may reach 25-37 °C, such as tropical regions.

POS0675 IMPACT OF PAST USE OF DISEASE MODIFYING ANTI-RHEUMATIC DRUGS ON JAK INHIBITOR TREATMENT FOR RHEUMATOID ARTHRITIS - DATA FROM THE FUKUI ISHIKAWA TOYAMA DATABASE OF RHEUMATOID ARTHRITIS

Background

Currently, five types of Janus kinase inhibitors (JAKis) are used for rheumatoid arthritis (RA) treatment. The number of cases in which multiple JAKis have been prescribed is increasing. However, the real-world efficacy and safety of JAKis and related factors require further evaluation.

Objectives

The primary objective of this study was to elucidate the impact of past use of disease-modifying anti-rheumatic drugs on RA treatment using JAKis. The secondary objective was to investigate the safety profiles of these agents in a real-world setting.

Methods

Of the 303 JAKi-treated patients in the Fukui Ishikawa Toyama Database of RA included in this study, 30 had switched from one JAKi to another (JJ group), 214 switched from a biologic agent to a JAKi (BJ group), and 47 were naïve to either biologics or JAKis (NJ group). We compared baseline factors, treatment response, and JAKi continuation rates among the three groups. Factors related to JAKi discontinuation were assessed using Cox regression analysis. Furthermore, we investigated adverse events and reported them using exposure-adjusted incidence rates (EAIR; incidence rates per 100 patient-years).

Results

Data from the 303 cases were analyzed (mean age = 63.6 years; female, 82%; mean RA duration, 176 months). Of the 303 patients, 118, 106, 50, and 29 were treated with tofacitinib, baricitinib, peficitinib, and upadacitinib, respectively, on initial observation. Rate of concomitant use with methotrexate and prednisolone was 52% and 49%, respectively.

Regarding efficacy, no significant differences were observed among the three groups in terms of treatment response and JAKi continuation rates, except for the 6-month treatment response between the JJ and NJ groups. Cox regression analysis of the 303 cases revealed that only past use of JAKis during the disease history was significantly associated with JAKi discontinuation. The Kaplan–Meier method showed that patients who previously used JAKis had significantly shorter median JAKi treatment duration than those without such a history (20.9 vs. 54.7 months; p = 0.012). Treatment response was significantly poor in patients who had previously used JAKis, especially 6 months after treatment initiation.

In terms of safety, the total exposure period for the 303 cases was 495 person-years, and the total number of adverse events was 161 (EAIR, 32.5). There were 12 cases (EAIR, 2.5) of serious infections, 23 cases (EAIR, 5.1) of herpes zoster, 7 cases (EAIR, 1.4) of malignant tumors, and 4 cases (EAIR, 0.8) of MACE. Adverse events led to JAKi discontinuation in 34 patients (EAIR, 6.9); the main causes of adverse events leading to treatment discontinuation were infectious diseases in 10 cases (EAIR, 2) and neoplasms in 4 cases (EAIR, 0.8). Within 1 year of initiating JAKi therapy, 21 patients discontinued treatment owing to adverse events, which accounted for 27% of the reasons for treatment discontinuation.

We also investigated cases of JAKi dose reduction, observed in 42 of the 303 cases. Among them, 10 patients required a re-increase in the JAKi dose, and 13 patients (56.5%) were able to maintain the reduced dose for more than 1 year. The remaining 19 patients were excluded from the analysis because the treatment duration at the lower dose had not exceeded 1 year at the time of data extraction. No difference in disease activity at the time of dose reduction was observed between those who maintained the new dose and those who did not (mean DAS28-CRP: 1.48 ± 0.26 vs. 1.89 ± 0.62).

Conclusion

Past use of JAKis may contribute to decreased response and continuation rates for JAKi treatment. In this study, conducted in Japan, development of herpes zoster was found to the most frequent adverse event among the priority survey items.

Acknowledgements

I have no acknowledgements to declare.

Disclosure of Interests

None declared

Dynamic changes in RAS gene status in circulating tumour DNA: a phase II trial of first-line FOLFOXIRI plus bevacizumab for RAS-mutant metastatic colorectal cancer (JACCRO CC-11)

Background

Few prospective studies have used liquid biopsy testing in RAS-mutant metastatic colorectal cancer (mCRC), and its clinical significance remains unknown. Therefore, this study aimed to carry out a biomarker analysis by liquid biopsy using updated data of the phase II trial of FOLFOXIRI plus bevacizumab as first-line chemotherapy for RAS-mutant mCRC.

Materials and methods

A total of 64 patients who received modified FOLFOXIRI regimen (irinotecan 150 mg/m², oxaliplatin 85 mg/m², levofolinate 200 mg/m², and fluorouracil 2400 mg/m²) plus bevacizumab biweekly were enrolled. The primary endpoint was the objective response rate (ORR). Plasma samples were collected at pre-treatment, 8 weeks after treatment, and progression in participants included in the biomarker study. The levels of circulating tumour DNA (ctDNA) and specific KRAS and NRAS variants were evaluated using real-time PCR assays.

Results

There were 62 patients (median age: 62.5 years, 92% performance status 0, 27% right side) who were assessable for efficacy and 51 for biomarker analysis. ORR was 75.8% (95% confidence interval 65.1% to 86.5%). The median progression-free survival was 12.1 months, and the median overall survival (OS) was 30.2 months. In 78% of patients, RAS mutations disappeared in the ctDNA at 8 weeks after treatment; these patients tended to have better outcomes than those with RAS mutations. Interestingly, RAS mutations remained undetectable during progression in 62% of patients. Survival analysis indicated that the median OS from progression was significantly longer in patients with RAS mutation clearance than in those with RAS mutation in the ctDNA at disease progression (15.1 versus 7.3 months, hazard ratio: 0.21, P = 0.0046).

Conclusions

Our biomarker study demonstrated no RAS mutations in ctDNA at disease progression in 62% of patients with RAS-mutant mCRC. Both OS and post-progression survival were better in patients with clearance of RAS mutations in ctDNA after triplet-based chemotherapy.

•

First-line FOLFOXIRI plus bevacizumab is effective for RAS-mutant mCRC with comparable efficacy in elderly patients.

•

RAS mutations disappeared in ctDNA after intensive chemotherapy in 62% of patients with mCRC with RAS-mutant tumours.

•

Survival time was longer in patients with RAS mutation clearance than in those with RAS mutations in ctDNA.

Responses of promyelocytic leukemia HL60 cells as an inflammatory cell lineage model to silica microparticles used to coat blood collection tubes

Background

The preparation of platelet-rich fibrin (PRF) requires glass blood collection tubes, and thus, the shortage or unavailability of such tubes has driven clinicians to search for suitable substitutes, such as silica-coated plastic tubes. However, we have previously demonstrated the cytotoxicity of silica microparticles (MPs) used in plastic tubes to cultured human periosteal cells. To further establish the effects of silica MPs on inflammation, we examined silica MP-induced changes in a human promyelocytic cell model in vitro.

Methods

Human promyelocytic HL60 cells were used either without chemical induction or after differentiation induced using phorbol myristate acetate (PMA) or dimethyl sulfoxide. HL60 cells, osteoblastic MG63, and Balb/c mouse cells were treated with silica MPs, and their surface ultrastructure and numbers were examined using a scanning electron microscope and an automated cell counter, respectively. Differentiation markers, such as acid phosphatase, non-specific esterase, and CD11b, were visualized by cytochemical and immunofluorescent staining, and superoxide dismutase (SOD) activity was quantified.

Results

Regardless of SOD activity, silica cytotoxicity was observed in MG63 and Balb/c cells. At sub-toxic doses, silica MPs slightly or moderately upregulated the differentiation markers of the control, PMA-induced monocytic, and dimethyl sulfoxide-induced granulocytic HL60 cells. Although SOD activity was the highest (P < 0.05) in PMA-induced cells, a silica-induced reduction in cell adhesion was observed only in those cells (P < 0.05).

Conclusions

Silica MP contamination of PRF preparations can potentially exacerbate inflammation at implantation sites. Consequently, unless biomedical advantages can be identified, silica-coated plastic blood collection tubes should not be routinely used for PRF preparations.

Genome-wide detection of non-additive quantitative trait loci for semen production traits in beef and dairy bulls

Semen production traits are important aspects of bull fertility, because semen quantity leads to direct profits for artificial insemination centres, and semen quality is associated with the probability of achieving a pregnancy. Most genome-wide association studies (GWASs) for semen production traits have assumed that each quantitative trait locus (QTL) has an additive effect. However, GWASs that account for non-additive effects are also important in fitness traits, such as bull fertility. Here, we performed a GWAS using models that accounted for additive and non-additive effects to evaluate the importance of non-additive effects on five semen production traits in beef and dairy bulls. A total of 65 463 records for 615 Japanese Black bulls (JB) and 50 734 records for 873 Holstein bulls (HOL), which were previously genotyped using the Illumina BovineSNP50 BeadChip, were used to estimate genetic parameters and perform GWAS. The heritability estimates were low (ranged from 0.11 to 0.23), and the repeatability estimates were low to moderate (ranged from 0.28 to 0.45) in both breeds. The estimated repeatability was approximately twice as high as the estimated heritability for all traits. In this study, only one significant region with an additive effect was detected in each breed, but multiple significant regions with non-additive effects were detected for each breed. In particular, the region at approximately 64 Mbp on Bos taurus autosome 17 had the highest significant non-additive effect on four semen production traits in HOL. The rs41843851 single nucleotide polymorphism (SNP) in the region had a much lower P-value for the non-additive effect (P-value = 1.1 × 10^-31) than for the additive effect (P-value = 1.1 × 10^-8) in sperm motility. The AA and AB genotypes on the SNP had a higher phenotype than the BB genotype in HOL, and there was no bull with the BB genotype in JB. Our results showed that non-additive QTLs affect semen production traits, and a novel QTL accounting for non-additive effects could be detected by GWAS. This study provides new insights into non-additive QTLs that affect fitness traits, such as semen production traits in beef and dairy bulls.

Impact of heart rate reduction on recurrence after catheter ablation of persistent atrial fibrillation

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Johnson & Johnson KK

OnBehalf

OCVC Arrhythmia Investigators

Background

Predicting heart rate (HR) after restoration of sinus rhythm (SR) remains one of the challenges when performing catheter ablation (CA) of persistent atrial fibrillation (AF).

Purpose

To evaluate the association between pre-ablation HR during AF and post-ablation HR during SR, and whether the HR reduction is associated with AF recurrence.

Methods

The analysis was performed from the EARNEST-PVI trial, a randomized controlled trial designed to assess a CA strategy for persistent AF, which was conducted in the Osaka region of Japan. After excluding patients with beta-blocker prescription, a total of 216 patients (median age, 67 years; 20% female; 23% long-standing persistent AF) with AF rhythm at baseline and SR at discharge were enrolled in this study. Baseline HR during AF and post-ablation HR during SR was measured on admission and at discharge using the 12-lead electrocardiograms, respectively.

Results

There was a mild correlation between baseline HR (median 82 [interquartile range 72-95] bpm) and post-ablation HR (78 [48-117] bpm) (r = 0.27, p &lt;0.001). Reduction in HR was positively associated with baseline HR (r = 0.79, p &lt;0.001) and was negatively associated with post-ablation HR (r = - 0.37, p &lt;0.001). During the follow-up of 1 year, 56 patients (25.9%) experienced AF recurrence. HR reduction had the higher diagnostic accuracy in predicting AF recurrence than HR at baseline and HR after CA (area under the curve, 0.625; 95% confidence interval, 0.557–0.690; p = 0.003). AF recurrence rate was significantly higher in 141 patients with smaller HR reduction (cut-off, &lt;14bpm) than those with larger HR reduction (31.9% vs. 14.7%, p = 0.009). After adjustment of age, gender, long-standing persistent AF, and CA strategy, HR reduction of &lt;14 bpm was a significant predictor of AF recurrence (hazard ratio, 2.32; 95% confidence interval, 1.20–4.51; p = 0.013).

Conclusions

There was a mild correlation between HR during AF and HR after restoration of SR in patients underwent CA of persistent AF. HR reduction after restoration of SR predicted AF recurrence.

Effects of SARS‑CoV‑2 mRNA vaccines on platelet polyphosphate levels and inflammation: A pilot study

Platelets function as immune cells in conjunction with white blood cells, targeting invading pathogens and inducing immune reactions. Intercellular communications among these immune cells are partly mediated by platelet polyphosphate (polyP), which was originally recognized as a thrombotic and hemostatic biomolecule. To determine the involvement of polyP in SARS-CoV-2-mRNA vaccine-induced immune responses, specifically in inflammatory responses, the effects of mRNA vaccines on platelet polyP levels were examined. Before and after vaccination with the COVID-19 vaccine (BNT162b2), blood samples were obtained from healthy, non-smoking individuals who did not have any systemic diseases. Test group demographics skewed somewhat towards either older males (first vaccination, n=6; second vaccination, n=8) or younger females (first vaccination, n=14; second vaccination, n=23). polyP levels in washed platelets from the blood samples were determined using the fluorometric method with DAPI. The side-effects of vaccination were recorded as scores. In the female group, platelet polyP levels decreased after the first vaccination, and the side-effect score increased after the second vaccination. Moderate correlation coefficients were observed between the reduction in polyP levels and the side-effect scores and pre-vaccination polyP levels. Despite the small sample size, this pilot study suggests that platelet polyP may suppress the side effects induced by the mRNA vaccines after the first vaccination, but not the second vaccination in younger female subjects, who generally have higher immune responsiveness than their male counterparts.

Iron lamination and interlaminar insulation for high-frequency pulsed magnets

In high-frequency pulsed magnets, such as kickers in particle accelerators, it is essential to reduce eddy currents that could be induced in the magnet core during excitation not to distort and attenuate the magnetic field pulse. A novel iron lamination scheme with additional interlaminar insulation is proposed for the magnet core of such pulsed magnets. A laminated steel sheet core is formed by alternately stacking thin steel and insulation sheets. For application to matched kicker magnets for accelerators, test magnets with the new and conventional iron lamination were designed, assembled, and extensively evaluated. The pulsed magnetic field waveforms of two test magnets with the new lamination successfully matched to below 0.1% over the entire pulse duration, which was significantly better than those with the conventional lamination. Among the applications of the developed high-frequency pulsed magnets, beam injection kickers for the coming next generation light sources and future colliders, where suppression of the transient stored-beam oscillation during beam injection is crucial, are considered to be promising.

Prognostic value of the combination of pulmonary-systemic pressure ratio and a new systemic inflammation-nutrition index in patients admitted for acute decompensated heart failure

Background

Concomitant presence of pulmonary hypertension in heart failure (HF) is associated with increased adverse events and may be related to interventricular uncoupling and impaired cardiac efficiency. It has recently been shown that an increased mean pulmonary artery pressure to mean systemic arterial pressure ratio (MPS ratio), a marker of interventricular coupling and efficiency, is associated with worse clinical outcomes in patients with advanced HF. On the other hand, systemic inflammation plays a critical role in the outcomes of heart failure, and malnutrition is also associated with poor outcome in heart failure patients It has been recently reported that advanced lung cancer inflammation index (ALI), which is calculated as body mass index × serum albumin / neutrophil to lymphocyte ratio (NLR), is an independent prognostic marker in several types of cancer. However, there is no information available on the prognostic value of the combination of MPS ratio and ALI in patients with acute decompensated HF (ADHF).

Methods and results

We studied 219 patients admitted for ADHF, who underwent right heart catheterization at the admission and were discharged with survival. During a follow up period of 5.1±4.2 yrs, 57 had cardiovascular death (CVD). MPS ratio was significantly greater (0.401±0.107 vs 0.346±0.105, p=0.0009) and ALI was significantly smaller (34.2±18.7 vs 52.0±27.1, p&lt;0.0001) in patients with than without CVD At multivariate Cox analysis, MPS ratio and ALIwere significantly associated with CVD, independently of eGFR and prior heart failure hospitalization, after the adjustment with left ventricular end-diastolic dimension and serum sodium level. The patients with both greater MPS ratio&gt;0.350 (AUC 0.652 [0.569–0.735]) and smaller ALI &lt;35.767 (AUC 0.714 [0.636–0.792]) had a significantly increased risk of CVD than those with either greater MPS or smaller ALI and none of them (67% vs 22% vs 11%, p&lt;0.0001, respectively).

Conclusion

The combination of MPS ratio and ALI might be useful for stratifying ADHF patients at higher risk for CVD.

Funding Acknowledgement

Type of funding sources: None.

Impact of low-dose or under-dose direct oral anticoagulant on coagulation and fibrinolytic markers in patients with atrial fibrillation

Background

Atrial fibrillation (AF) is known to increase the risks of cerebral and systemic embolism. Apart from vitamin K antagonists, edoxaban, a direct oral anticoagulant (DOAC), has been approved for oral anticoagulation in patients with non-valvular AF. On the other hand, DOACs are sometimes prescribed at off-label under-doses for patients who have undergone ablation for AF. Prothrombin fragment F1+2 is an activation peptide released from prothrombin during thrombin formation. The purpose of this study is to compare the effects of DOAC doses on coagulation and fibrinolytic markers.

Methods and results

A total of 88 patients with AF (age: 68±11 years, male:45%, paroxysmal AF n=49, persistent AF n=39) were recruited. All patients were received edoxaban (60mg or 30mg) once a day. For the purpose of the study, patients were divided into three groups according to whether they had been treated before the ablation procedure under an appropriate standard dose group (n=30 [34.1%]), appropriate low-dose group (n=35 [39.8%]), or off-label under-dose group (n=23 [26.1%]). We examined the coagulation and fibrinolytic markers, and echocardiographic parameters before ablation. All patients were followed up for 12 months after AF ablation. Creatinine clearance was significantly higher in appropriate standard-dose group than in appropriate low-dose or off-label under-dose group (101.1±38.4, 57.1±15.9 and 73.2±14.6 mL/min, respectively; P&lt;0.001). There were no significant baseline differences in AF type, history of stroke/transient ischemic attack (TIA), plasma B-type natriuretic peptide, protein C, fibrinogen, D-dimer level, left ventricular ejection fraction or left atrium dimension among the three groups. Prothrombin fragment F1+2 level was significantly lower in the appropriate standard-dose group than the appropriate low-dose and off-label under-dose groups (105.9±29.4, 142.6±41.3 and 142.8±84.9 pmol/L, respectively; P=0.011, Figure). One patient in the appropriate low-dose group had a TIA and 1 patient in the off-label under-dose group had a bleeding event during the follow up period after ablation.

Conclusion

Our results suggest that an appropriate standard dose of edoxaban is needed to suppress hypercoagulability in patients with AF.

Funding Acknowledgement

Type of funding sources: None. Prothrombin fragment F1+2 level

Effect of endothelial nitric oxide synthase gene polymorphism on cardiovascular death and nonfatal myocardial infarction in Japanese general population

Introduction

Single nucleotide polymorphisms (SNP) of endothelial nitric oxide synthase (NOS3) have been reported to be associated with diabetes mellitus and myocardial infarction. However, few reports have prospectively investigated the effects of NOS3 SNP on cardiovascular death and nonfatal myocardial infarction.

Purpose

The purpose of this study was to investigate the impact of NOS3 SNP on cardiovascular death and the development of nonfatal myocardial infarction.

Methods

This prospective cohort study included 2,752 subjects (aged ≥40) who participated in a community based health checkup. We genotyped two SNPs within NOS3 (rs1808593, rs1799983). All subjects were prospectively followed during the median follow-up period of 15.4 years with the end point of cardiovascular death and nonfatal myocardial infarction.

Results

The homozygous G-allele (GG), heterozygous (GT), and homozygous T-allele (TT) carriers of rs1808593 were identified in 60 (2%), 706 (26%), and 1,986 (72%) subjects, respectively. Kaplan-Meier analysis demonstrated that homozygous G-allele carriers of rs1808593 had the greater risk than those without. Multivariate Cox proportional hazard regression analysis revealed that the homozygous G allele of rs1808593 was associated with cardiovascular death and the development of nonfatal myocardial infarction after adjusting for confounding risk factors.

Conclusions

NOS3 gene polymorphism could be a genetic risk factor for cardiovascular death and nonfatal myocardial infarction in the Japanese general population.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Prognostic value of sarcopenia and malnutrition in patients admitted for acute decompensated heart failure with reduced or preserved left ventricular ejection fraction

Background

Sarcopenia and malnutrition are associated with poor clinical outcome in patients with chronic heart failure. However, there is little information available on the prognostic significance of the combination of sarcopenia and malnutrition in patients with acute decompensated heart failure (ADHF), relating to reduced or preserved left ventricular ejection fraction (HFrEF or HFpEF).

Methods

We prospectively studied 543 consecutive ADHF patients who survived to discharge (HFrEF [LVEF &lt;45%] n=245 and HFpEF [LVEF≥45%] n=298). At the discharge, sarcopenia and malnutrition was evaluated by free-fat mass index (FFMI) and geriatric nutrition risk index (GNRI), respectively. FFMI was calculated as follows: FFMI = (7.38 + 0.02908 × urinary creatinine [mg/day])/ (height in meter)2. Sarcopenia was defined as FFMI &lt;17 kg/m2 in men and &lt;15 kg/m2 in women. GNRI was calculated as follows: 14.89 × serum albumin (g/dl) + 41.7 × BMI/22, and malnutrition was defined as GNRI&lt;92. The endpoint was all-cause death.

Results

During a follow-up period of 2.8±1.4 years, 161 patients had all-cause death. Multivariate Cox analysis showed that both FFMI and GNRI were independently associated with all-cause death in both HFrEF (p=0.0064 and p&lt;0.0001, respectively) and HFpEF patients (p=0.0140 and p=0.0007, respectively) after adjustment for relevant baseline clinical and study characteristics. In HFrEF, patients with both sarcopenia and malnutrition had a significantly higher risk of the total mortality than those with either or none of them. On the other hand, in HFpEF, patients with both and either sarcopenia or malnutrition had a significantly higher risk of the total mortality than those with none of them, while there was no significant difference in the risk between both and either sarcopenia or malnutrition.

Conclusions

Sarcopenia or malnutrition at discharge was associated with all-cause death even in ADHF patients, irrespective of reduced or preserved LVEF. The combination of sarcopenia and malnutrition could provide prognostic information in ADHF patients with reduced LVEF.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Reappraising the role of baseline plasma C-reactive protein levels on recurrence after catheter ablation of persistent atrial fibrillation: insight from EARNEST-PVI trial

Background

Subclinical inflammation is an important pathogenesis of developing and sustaining atrial fibrillation (AF). Because AF itself contribute to the inflammatory response, the role of baseline subclinical inflammation on AF recurrence after catheter ablation (CA) remains controversial in patients with persistent AF.

Purpose

To evaluate whether baseline plasma C-reactive protein (CRP) levels, a sensitive marker of inflammation, are associated with AF recurrence following CA.

Methods

The analysis was performed from the EARNEST-PVI trial, a randomized controlled trial designed to assess a CA strategy for persistent AF, which was conducted in the Osaka region of Japan. A total of 441 patients (median age, 67 years; 26% female; 25% long-standing persistent AF) whose plasma CRP levels were measured at baseline were included in this study.

Results

At baseline, a median (interquartile range) of plasma CRP level was 0.10 [0.06–0.19] mg/dl. Plasma CRP levels significantly increased at discharge (0.83 [0.21–1.84] mg/dl, p&lt;0.001) and decreased 1 year after CA (0.10 [0.05–0.20] mg/dl, p=0.040) compared to the baseline value. During the follow-up of 1 year, 115 patients (26%) experienced AF recurrence, and the incidence was significantly higher in 124 patients with low CRP levels at baseline (cut-off ≤0.06 mg/dl) than the other 317 patients (33.9% vs. 23.0%, p=0.017). After adjustment of age, gender, body mass index, long-standing persistent AF, CA strategy, and plasma brain natriuretic peptide levels, low plasma CRP levels was a significant predictor of AF recurrence (hazard ratio, 1.51; 95% confidence interval, 1.02–2.24; p=0.042).

Conclusions

Low plasma CRP levels at baseline predicted AF recurrence in the EARNEST-PVI trial. Reappraising the role of CRP on AF recurrence may be needed in patients with persistent AF.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Johnson & Johnson KK

Prognostic value of simple risk index and plasma volume status in patients with acute decompensated heart failure

Background

Increased heart rate (HR) and low systolic blood pressure (SBP) are associated with adverse clinical outcomes in patients admitted for acute decompensated heart failure (ADHF), and simple risk index (SRI) based on easily assessed clinical characteristics (age, HR, and SBP) provides prognostic information. On the other hand, plasma volume (PV) expansion plays an essential role in heart failure, and PV status is has been reported to be associated with adverse outcomes in ADHF patients. However, there is no information available on the value of the combination of SRI and PV status in patients admitted for ADHF.

Methods and results

We studied 301 patients admitted for ADHF. At the admission, SRI was calculated as (HR x [age/10]2)/SBP. PV status was calculated as the following: Actual PV = (1 − hematocrit) x [a + (b x body weight)] (a=1530 in males and a=864 in females, b=41 in males and b=47.9 in females), Ideal PV = c x body weight (c=39 in males and c=40 in females), and PV status = [(actual PV − ideal PV)/ideal PV] x 100(%). During a follow-up period of 4.3±3.2 yrs, 95 patients had all-cause death (ACD) and 68 patients had cardiovascular death (CVD). At multivariate Cox analysis, SRI and PV status were significantly associated with ACD and CVD, independently of the prior history of heart failure hospitalization and serum creatinine and sodium levels, after the adjustment with serum albumin level and anemia. Patients with both greater SRI (≥35.1 by ROC analysis; AUC 0.599 [0.524–0.674]) and greater PV status (≥8.1% by ROC analysis; AUC 0.625 [0.550–0.700]) had a significantly higher risk of ACD and CVD than those with either or none of them (ACD: 49% vs 27% vs 24%, p&lt;0.0001, CVD: 39% vs 18% vs 15%, p&lt;0.0001,respectively).

Conclusion

The combination of SRI and PV status might be useful for stratifying patients at risk for the total mortality and cardiovascular death in patients with ADHF.

Funding Acknowledgement

Type of funding sources: None.

Prognostic factors in patients with acute myocardial infarction underwent extracorporeal membrane oxygenation in hospital or out-of-hospital cardiac arrest

Background

Patients with acute myocardial infarction (AMI) who require extracorporeal membrane oxygenation (ECMO) have worse outcomes than those who do not, and patients with AMI with out-of-hospital cardiac arrest (OHCA) also have worse outcomes than those without OHCA. However, there have been still unclear points regarding the prognostic factors of AMI patients who underwent ECMO with or without OHCA. The aim of this study was to investigate the prognostic factors of AMI patients who underwent ECMO with and without OHCA, respectively.

Methods/Results

Ninety-eight consecutive patients (age:67±11 years, male:83.7%) who underwent ECMO for AMI were enrolled from November 2008 to December 2020. The primary endpoint was in-hospital mortality within 30-day, and we investigated the risk factors associated with 30-day mortality in AMI patients underwent ECMO with or without OHCA, respectively. In the group with OHCA (n=47), 30-day death occurred in 22 patients (47%). BMI, lactate and serum creatinine levels after the introduction of ECMO were significantly greater in patients with than without 30-day death (27.0±5.2 vs 21.0±2.9 kg/m2, p&lt;0.001, 12.1±4.3 vs 7.5±3.6 mmol/L, p&lt;0.001, 1.68±1.24 vs 1.41±1.07 mg/dL, p=0.039, respectively). The multivariate regression analysis showed that lactate level was independently associated with the poor outcome (Odds ratio: 1.32, 95% CI: 1.11–1.57, p&lt;0.001). ROC curve analysis showed that the cut-off values: 7.8mmol/L of lactate had moderate accuracy to predict 30-day mortality (sensitivity:76%, specificity:86%, AUC:0.81). In the group without OHCA (n=51), 30-day death occurred in 20 patients (39%). The frequency of ventricular tachycardia / fibrillation (VT/VF) at initiation of ECMO was significantly higher (61.3% vs 25.0%, p=0.021), the frequency of mechanical complication was significantly lower (6.5% vs 30.0%, p=0.045) in patients without 30-day death than with 30-day death. The multivariate regression analysis showed that VT/VF at initiation of ECMO was independently associated with good outcome (Odds ratio: 0.21, 95% CI: 0.06–0.73, p=0.01).

Conclusions

With OHCA, increased lactate was the risk factor that was significantly associated with poor outcome in AMI patients underwent ECMO. Without OHCA, AMI patients who underwent ECMO due to rhythm trouble such as VT/VF had a good outcome. ECMO patients with AMI may have different prognostic factors with or without OHCA.

Funding Acknowledgement

Type of funding sources: None. Patient characteristics

Renal function and arrhythmia outcomes in persistent atrial fibrillation patients after catheter ablation: subanalysis of the EARNEST-PVI trial

Background

Atrial fibrillation (AF) reduces the renal function. Renal dysfunction and AF often coexist. Catheter ablation (CA) of persistent AF can maintain a sinus rhythm and may improve the renal function.

Purpose

We sought to elucidate whether the estimated glomerular filtration rate (eGFR) in patients with persistent AF was increased after CA, especially with the presence of an AF recurrence.

Methods

We enrolled 487 persistent AF patients whose eGFR data were available both before and 1-year after the CA out of 512 patients in the EARNEST-PVI trial.

Results

The mean age was 65±9 year and 113 patients (24.8%) had long-standing persistent AF. We compared the eGFR at baseline with that 1-year after the CA. AF recurrences were recognized in 118 patients (25.8%). The eGFR was similar between the group without recurrence and that with recurrence at baseline (without AF recurrence vs. with AF recurrence; 63.8±14.3 vs. 62.7±13.6 mL/min/1.73m2, p=0.46). In patients without AF recurrence, the G1, G2, G3a, G3b, G4, and G5 were 13 (3.8%), 198 (58.4%), 98 (28.9%), 26 (7.7%), 3 (0.9%), and 1 (0.3%), respectively at baseline. In the patients with AF recurrence, the G1, G2, G3a, G3b, G4, and G5 were 3 (2.5%), 68 (57.8%), 38 (32.2%), 6 (5.1%), 3 (2.5%), and 0 (0%), respectively at baseline. The ΔeGFR was significantly higher in the patients without AF recurrence than in those with AF recurrence (without AF recurrence vs. with AF recurrence; 5.1 [−0.3, 10.8] vs. 3.0 [−3.0, 7.6], p=0.0033). In the patients without AF recurrence, a better eGFR class at 1-year after the CA than in those before the CA was recognized in 75 patients (22.1%), while it was recognized in 19 patients (16.1%) with AF recurrences.

Conclusion

Successful catheter ablation in patients with persistent AF led to a better renal outcome.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): This study was funded by Medtronic, Johnson & Johnson, and Abbott.

The impact of substrate and trigger ablation for reduction of functional mitral regurgitation in patients with persistent atrial fibrillation

Background

Functional mitral regurgitation (FMR) is not uncommon in atrial fibrillation (AF) patients. Left atrial (LA) substrate remodeling and corresponding mitral valve annulus dilation has been reported as the most possible cause of FMR. Percutaneous catheter ablation (CA) is an effective treatment for AF. Although significant FMR could be improved by sinus restoration, patients with mitral regurgitation were more likely to experience recurrent AF post ablation, especially those with significant mitral regurgitation. There is no information available on the efficacy of CA for persistent AF in patients with FMR.

Purpose

The purpose of this study is to investigate the predictors of FMR improvement by CA and to determine the efficacy of substrate and trigger CA for persistent AF in patients with FMR.

Methods

We prospectively studied 512 consecutive patients admitted for persistent AF ablation from the EARNEST-PVI (Prospective Multicenter Randomized Study of Effect of Extensive Ablation on Recurrence in Patients with Persistent Atrial Fibrillation Treated with Pulmonary Vein Isolation) trial.

On admission, enrolled patients were randomly assigned in a 1:1 ratio to pulmonary vein isolation (PVI) or PVI-plus additional ablation (linear ablation or/and CFAE ablation). Of the 512 patients, we studied 94 patients with preoperative echocardiography showing moderate or greater baseline FMR. FMR grades were classified into 5 grades (0/1/2/3/4). The FMR improvement group (FMRI(+)) was defined as a case in which the FMR was improved by two or more grades compared the preoperative echocardiography and the one year follow-up examination.

Results

Of the 94 patients, 42 were in the PVI group and 52 were in the PVI-plus additional ablation group. There were 30 cases in the FMRI(+) group and 64 cases in the FMRI(−) group. There were no significant baseline differences in age, sinus rhythm maintenance, plasma B-type natriuretic peptide (BNP) level, left ventricular diastolic dimension, or left atrium dimension between the FMRI(+) and FMRI(−) groups. AF duration was significantly shorter in the FMRI(+) group than FMRI(−) groups (5.8±9.4 months vs 12.4±15.4 months, p&lt;0.0001). In addition, significantly more additional ablation cases were observed in the FMRI(+) group than in the FMRI(−) group (73.3% vs 46.8%, p=0.016). In multivariate analyses, only additional ablation was an independent predictor of FMRI (odds ratio 0.226 95% CI 0.081–0.626; p=0.004).

Conclusions

Catheter ablation is a valid option for the treatment of AF in patients with functional MR and additional substrate and trigger ablation were the only independent predictor of FMR improvement.

Funding Acknowledgement

Type of funding sources: None.

Prognostic value of a new systemic inflammation-nutrition index in patients admitted with acute decompensated heart failure; a comparison with malnutrition

Background

Systemic inflammation plays a critical role in the outcomes of heart failure. Malnutrition is also associated with poor outcome in heart failure patients. It has been recently reported that advanced lung cancer inflammation index (ALI), which is calculated as body mass index × serum albumin / neutrophil to lymphocyte ratio (NLR), is an independent prognostic marker in several types of cancer. However, there is no information available on the prognostic impact of ALI in patients admitted with acute decompensated heart failure (ADHF), especially in comparison with malnutrition.

Methods and results

We studied 263 ADHF patients discharged with survival. At the discharge, we measured ALI. Malnutrition was assessed by prognostic nutritional index (PNI) and controlling nutritional status score (CONUT). During a follow up period of 5.1±4.3 yrs, 67 patients had cardiovascular death (CVD). ALI was significantly smaller in patients with than without CVD (32.5±18.2 vs 52.2±30.2, p&lt;0.0001). At multivariate Cox regression analysis, ALI was significantly associated with CVD, independently of prior heart failure hospitalization, systolic blood pressure and eGFR, although PNI and CONUT showed the association with CVD at unvariate analysis. By receiver-operator curve analysis, AUC of ALI was 0.733 (0.664–0.803), which was significantly greater than that of PNI (0.664 [0.590–0.739]) and CONUT (0.591 [0.509–0.672]). Patients with lowest tertile of ALI (&lt;32.0) had a increased risk of mortality than middle tertile (NLR=32.0–53.6; HR 2.06 [1.15–3.71]) and highest tertile (ALI&gt;53.6: HR 5.80 [2.60–12.94]) (48% vs 21% vs 9%, p&lt;0.0001, respectively).

Conclusion

ALI, a systemic inflammation-nutrition index, is more useful prognostic marker than malnutrition in patients admitted with ADHF.

Funding Acknowledgement

Type of funding sources: None.